National Registry Skill Sheets

Transcription

1 Airway, Oxygen and Ventilation Skills/Upper Airway Adjuncts and Suction Bag-Valve-Mask/Apneic Patient Bleeding Control/Shock Management Cardiac Arrest Management/AED Immobilization Skills/Joint Injury Immobilization Skills/Long Bone Injury Immobilization Skills/Traction Splinting Mouth to Mask With Supplemental Oxygen Oxygen Administration Patient Assessment/Management Medical Patient Assessment/Management Trauma Spinal Immobilization/Seated Patient Spinal Immobilization/Supine Patient Ventilatory Management/Dual Lumen Device Insertion Following an Unsuccessful Endotracheal Intubation Attempt Ventilatory Management/Endotracheal Intubation Ventilatory Management/Esophageal Obturator Airway Insertion Following an Unsuccessful Endotracheal Intubation Attempt

2 Airway, Oxygen and Ventilation Skills Upper Airway Adjuncts and Suction OROPHARYNGEAL AIRWAY Selects appropriately sized airway 1 Measures airway 1 Inserts airway without pushing the tongue posteriorly 1 Note: The examiner must advise the candidate that the patient is gagging and becoming conscious Removes the oropharyngeal airway 1 SUCTION Note: The examiner must advise the candidate to suction the patient s airway Turns on/prepares suction device 1 Assures presence of mechanical suction 1 Inserts the suction tip without suction 1 Applies suction to the oropharynx/nasopharynx 1 NASOPHARYNGEAL AIRWAY Note: The examiner must advise the candidate to insert a nasopharyngeal airway Selects appropriately sized airway 1 Measures airway 1 Verbalizes lubrication of the nasal airway 1 Fully inserts the airway with the bevel facing toward the septum 1 TOTAL: 13 Did not take, or verbalize, body substance isolation precautions Did not obtain a patent airway with the oropharyngeal airway Did not obtain a patent airway with the nasopharyngeal airway Did not demonstrate an acceptable suction technique Inserted any adjunct in a manner dangerous to the patient

3 Bag-Valve-Mask Apneic Patient Voices opening the airway 1 Voices inserting an airway adjunct 1 Selects appropriately sized mask 1 Creates a proper mask-to-face seal 1 Ventilates patient at no less than 800 ml volume (The examiner must witness for at least 30 seconds) 1 Connects reservoir and oxygen 1 Adjusts liter flow to 15 liters/minute or greater 1 The examiner indicates arrival of a second EMT. The second EMT is instructed to ventilate the patient while the candidate controls the mask and the airway Voices re-opening the airway 1 Creates a proper mask-to-face seal 1 Instructs assistant to resume ventilation at proper volume per breath 1 (The examiner must witness for at least 30 seconds) TOTAL: 11 Did not take, or verbalize, body substance isolation precautions Did not immediately ventilate the patient Interrupted ventilations for more than 20 seconds Did not provide high concentration of oxygen Did not provide, or direct assistant to provide, proper volume/breath (more than two (2) ventilations per minute are below 800 ml) Did not allow adequate exhalation

4 Bleeding Control/Shock Management Applies direct pressure to the wound 1 Elevates the extremity 1 Note: The examiner must now inform the candidate that the wound continues to bleed. Applies an additional dressing to the wound 1 Note: The examiner must now inform the candidate that the wound still continues to bleed. The second dressing does not control the bleeding. Locates and applies pressure to appropriate arterial pressure point 1 Note: The examiner must now inform the candidate that the bleeding is controlled Bandages the wound 1 Note: The examiner must now inform the candidate the patient is now showing signs and symptoms indicative of hypoperfusion Properly positions the patient 1 Applies high concentration oxygen 1 Initiates steps to prevent heat loss from the patient 1 Indicates the need for immediate transportation 1 TOTAL: 10 Did not take, or verbalize, body substance isolation precautions Did not apply high concentration of oxygen Applied a tourniquet before attempting other methods of bleeding control Did not control hemorrhage in a timely manner Did not indicate a need for immediate transportation

5 Cardiac Arrest Management/AED ASSESSMENT Briefly questions the rescuer about arrest events 1 Directs rescuer to stop CPR 1 Verifies absence of spontaneous pulse (skill station examiner states no pulse ) 1 Directs resumption of CPR 1 Turns on defibrillator power 1 Attaches automated defibrillator to the patient 1 Directs rescuer to stop CPR and ensures all individuals are clear of the patient 1 Initiates analysis of the rhythm 1 Delivers shock (up to three successive shocks) 1 Verifies absence of spontaneous pulse (skill station examiner states no pulse ) 1 TRANSITION Directs resumption of CPR 1 Gathers additional information about arrest event 1 Confirms effectiveness of CPR (ventilation and compressions) 1 INTEGRATION Verbalizes or directs insertion of a simple airway adjunct (oral/nasal airway) 1 Ventilates, or directs ventilation of, the patient 1 Assures high concentration of oxygen is delivered to the patient 1 Assures CPR continues without unnecessary/prolonged interruption 1 Re-evaluates patient/cpr in approximately one minute 1 Repeats defibrillator sequence 1 TRANSPORTATION Verbalizes transportation of patient 1 TOTAL: 21 Did not take, or verbalize, body substance isolation precautions Did not evaluate the need for immediate use of the AED Did not direct initiation/resumption of ventilation/compressions at appropriate times Did not assure all individuals were clear of patient before delivering each shock Did not operate the AED properly (inability to deliver shock) Prevented the defibrillator from delivering indicated stacked shocks

6 Immobilization Skills Joint Injury Directs application of manual stabilization of the shoulder injury 1 Assesses motor, sensory and circulatory function in the injured extremity 1 Note: The examiner acknowledges motor, sensory and circulatory function are present and normal. Selects the proper splinting material 1 Immobilizes the site of the injury 1 Immobilizes the bone above the injured joint 1 Immobilizes the bone below the injured joint 1 Reassesses motor, sensory and circulatory function in the injured extremity 1 Note: The examiner acknowledges motor, sensory and circulatory function are present and normal. TOTAL: 8 Did not support the joint so that the joint did not bear distal weight Did not immobilize the bone above and below the injured site Did not reassess motor, sensory and circulatory function in the injured extremity before and after splinting

7 Immobilization Skills Long Bone Injury Directs application of manual stabilization of the injury 1 Assesses motor, sensory and circulatory function in the injured extremity 1 Note: The examiner acknowledges motor, sensory and circulatory function are present and normal Measures the splint 1 Applies the splint 1 Immobilizes the joint above the injury site 1 Immobilizes the joint below the injury site 1 Secures the entire injured extremity 1 Immobilizes the hand/foot in the position of function 1 Reassesses motor, sensory and circulatory function in the injured extremity 1 Note: The examiner acknowledges motor, sensory and circulatory function are present and normal TOTAL: 10 Grossly moves the injured extremity Did not immobilize the joint above and the joint below the injury site Did not reassess motor, sensory and circulatory function in the injured extremity before and after splinting

8 Immobilization Skills Traction Splinting Directs application of manual stabilization of the injured leg 1 Directs the application of manual traction 1 Assesses motor, sensory and circulatory function in the injured extremity 1 Note: The examiner acknowledges motor, sensory and circulatory function are present and normal Prepares/adjusts splint to the proper length 1 Positions the splint next to the injured leg 1 Applies the proximal securing device (e.g., ischial strap) 1 Applies the distal securing device (e.g., ankle hitch) 1 Applies mechanical traction 1 Positions/secures the support straps 1 Re-evaluates the proximal/distal securing devices 1 Reassesses motor, sensory and circulatory function in the injured extremity 1 Note: The examiner acknowledges motor, sensory and circulatory function are present and normal Note: The examiner must ask the candidate how he/she would prepare the patient for transportation Verbalizes securing the torso to the long board to immobilize the hip 1 Verbalizes securing the splint to the long board to prevent movement of the splint 1 TOTAL: 14 Loss of traction at any point after it was applied Did not reassess motor, sensory and circulatory function in the injured extremity before and after splinting The foot was excessively rotated or extended after splint was applied Did not secure the ischial strap before taking traction Final immobilization failed to support the femur or prevent rotation of the injured leg Secured the leg to the splint before applying mechanical traction Note: If the Sagar splint or the Kendricks Traction Device is used without elevating the patient s leg, application of manual traction is not necessary. The candidate should be awarded one (1) point as if manual traction were applied. Note: If the leg is elevated at all, manual traction must be applied before elevating the leg. The ankle hitch may be applied before elevating the leg and used to provide manual traction.

9 Mouth to Mask With Supplemental Oxygen Connects one-way valve to mask 1 Opens patient s airway or confirms patient s airway is open (manually or with adjunct) 1 Establishes and maintains a proper mask to face seal 1 Ventilates the patient at the proper volume and rate ( ml per breath/10-20 breaths per minute) 1 Connects the mask to high concentration of oxygen 1 Adjusts flow rate to at least 15 liters per minute 1 Continues ventilation of the patient at the proper volume and rate ( ml per breath/10-20 breaths per minute) 1 Note: The examiner must witness ventilations for at least 30 seconds TOTAL: 8 Did not take, or verbalize, body substance isolation precautions Did not adjust liter flow to at least 15 liters per minute Did not provide proper volume per breath (more than 2 ventilations per minute were below 800 ml) Did not ventilate the patient at a rate a breaths per minute Did not allow for complete exhalation

10 Oxygen Administration Assembles the regulator to the tank 1 Opens the tank 1 Checks for leaks 1 Checks tank pressure 1 Attaches non-rebreather mask to oxygen 1 Prefills reservoir 1 Adjusts liter flow to 12 liters per minute or greater 1 Applies and adjusts the mask to the patient s face 1 Note: The examiner must advise the candidate that the patient is not tolerating the non-rebreather mask. The medical director has ordered you to apply a nasal cannula to the patient. Attaches nasal cannula to oxygen 1 Adjusts liter flow to six (6) liters per minute or less 1 Applies nasal cannula to the patient 1 Note: The examiner must advise the candidate to discontinue oxygen therapy Removes the nasal cannula from the patient 1 Shuts off the regulator 1 Relieves the pressure within the regulator 1 TOTAL: 15 Did not take, or verbalize, body substance isolation precautions Did not assemble the tank and regulator without leaks Did not prefill the reservoir bag Did not adjust the device to the correct liter flow for the non-rebreather mask (12 liters per minute or greater) Did not adjust the device to the correct liter flow for the nasal cannula (6 liters per minute or less)

11 Patient Assessment/Management Medical SCENE SIZE-UP Determines the scene is safe 1 Determines the mechanism of injury/nature of illness 1 Determines the number of patients 1 Requests additional help if necessary 1 Considers stabilization of spine 1 INITIAL ASSESSMENT Verbalizes general impression of the patient 1 Determines responsiveness/level of consciousness 1 Determines chief complaint/apparent life threats 1 Assessment 1 Assesses airway and breathing Indicates appropriate oxygen therapy 1 Assures adequate ventilation Assesses/controls major bleeding 1 Assesses circulation Assesses pulse 1 Assesses skin (color, temperature, and condition) 1 Identifies priority patients/makes transport decisions 1 FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT Signs and symptoms (Assess history of present illness) 1 Altered Mental Allergic Poisoning/ Environmental Respiratory Cardiac Status Reaction Overdose Emergency Obstetrics Behavioral Onset? Provokes? Quality? Radiates? Severity? Time? Interventions? Onset? Provokes? Quality? Radiates? Severity? Time? Interventions? Description of the episode. Onset? Duration? Associated Symptoms? Evidence of Trauma? Interventions? Seizures? Fever? History of allergies? What were you exposed to? How were you exposed? Effects? Progression? Interventions? Substance? When did you ingest/become exposed? How much did you ingest? Over what time period? Interventions? Estimated weight? Source? Environment? Duration? Loss of consciousness? Effects general or local? Are you How do you pregnant? feel? How long Determine have you suicidal been tendencies. pregnant? Is the patient Pain or a threat to contractions? self or others? Bleeding or Is there a discharge? medical Do you feel problem? the need to Interventions? push? Last menstrual period?

12 Patient Assessment/Management Medical (continued) Allergies 1 Medications 1 Past pertinent history 1 Last oral intake 1 Event leading to present (rule out trauma) 1 Performs focused physical examination (assesses affected body part/system or, if indicated, completes rapid assessment) 1 Vitals (obtains baseline vital signs) 1 Interventions (obtains medical direction or verbalizes standing order for medication interventions and verbalizes proper additional intervention/treatment) 1 Transport (re-evaluates the transport decision) 1 Verbalizes the consideration for completing a detailed physical examination 1 ONGOING ASSESSMENT (verbalized) Repeats initial assessment 1 Repeats vital signs 1 Repeats focused assessment regarding patient complaint or injuries 1 TOTAL: 30 Did not take, or verbalize, body substance isolation precautions when necessary Did not determine scene safety Did not obtain medical direction or verbalize standing orders for medical interventions Did not provide high concentration of oxygen Did not find or manage problems associated with airway, breathing, hemorrhage or shock (hypoperfusion) Did not differentiate patient s need for transportation versus continued assessment at the scene Did detailed or focused history/physical examination before assessing the airway, breathing and circulation Did not ask questions about the present illness Administered a dangerous or inappropriate intervention

13 Patient Assessment/Management Trauma SCENE SIZE-UP Determines the scene is safe 1 Determines the mechanism of injury 1 Determines the number of patients 1 Requests additional help if necessary 1 Considers stabilization of spine 1 INITIAL ASSESSMENT Verbalizes general impression of the patient 1 Determines responsiveness/level of consciousness 1 Determines chief complaint/apparent life threats 1 Assessment 1 Assesses airway and breathing Initiates appropriate oxygen therapy 1 Assures adequate ventilation 1 Injury management 1 Assesses/controls major bleeding 1 Assesses circulation Assesses pulse 1 Assesses skin (color, temperature and condition) 1 Identifies priority patients/makes transport decision 1 FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT Selects appropriate assessment (focused or rapid assessment) 1 Obtains, or directs assistance to obtain, baseline vital signs 1 Obtains S.A.M.P.L.E. history 1 DETAILED PHYSICAL EXAMINATION Inspects and palpates the scalp and ears 1 Assesses the head Assesses the eyes 1 Assesses the facial areas including oral and nasal areas 1 Inspects and palpates the neck 1 Assesses the neck Assesses for JVD 1 Assesses for tracheal deviation 1 Inspects 1 Assesses the chest Palpates 1 Auscultates 1 Assesses the abdomen 1 Assesses the abdomen/pelvis Assesses the pelvis 1 Verbalizes assessment of genitalia/perineum as needed 1

14 Patient Assessment/Management Trauma (continued) Assesses the extremities 1 point for each extremity 4 includes inspection, palpation, assessment of motor, sensory and circulatory function Assesses the posterior Assesses thorax 1 Assesses lumbar 1 Manages secondary injuries and wounds appropriately 1 1 point for appropriate management of the secondary injury/wound Verbalizes re-assessment of the vital signs 1 TOTAL: 40 Did not take, or verbalize, body substance isolation precautions Did not determine scene safety Did not assess for spinal protection Did not provide for spinal protection when indicated Did not provide high concentration of oxygen Did not find, or manage, problems associated with airway, breathing, hemorrhage or shock (hypoperfusion) Did not differentiate patient s need for transportation versus continued assessment at the scene Did other detailed physical examination before assessing the airway, breathing and circulation Did not transport patient within (10) minute time limit

15 Spinal Immobilization Seated Patient Directs assistant to place/maintain head in the neutral in-line position 1 Directs assistant to maintain manual immobilization of the head 1 Reassesses motor, sensory and circulatory function in each extremity 1 Applies appropriately sized extrication collar 1 Positions the immobilization device behind the patient 1 Secures the device to the patient s torso 1 Evaluates torso fixation and adjusts as necessary 1 Evaluates and pads behind the patient s head as necessary 1 Secures the patient s head to the device 1 Verbalizes moving the patient to a long board 1 Reassesses motor, sensory and circulatory function in each extremity 1 TOTAL: 12 Did not immediately direct, or take, manual immobilization of the head Released, or ordered release of, manual immobilization before it was maintained mechanically Patient manipulated, or moved excessively, causing potential spinal compromise Device moved excessively up, down, left or right on the patient s torso Head immobilization allows for excessive movement Torso fixation inhibits chest rise, resulting in respiratory compromise Upon completion of immobilization, head is not in the neutral position Did not assess motor, sensory and circulatory function in each extremity after voicing immobilization to the long board Immobilized head to the board before securing the torso

16 Spinal Immobilization Supine Patient Directs assistant to place/maintain head in the neutral in-line position 1 Directs assistant to maintain manual immobilization of the head 1 Reassesses motor, sensory and circulatory function in each extremity 1 Applies appropriately sized extrication collar 1 Positions the immobilization device appropriately 1 Directs movement of the patient onto the device without compromising the integrity of the spine 1 Applies padding to voids between the torso and the board as necessary 1 Immobilizes the patient s torso to the device 1 Evaluates and pads behind the patient s head as necessary 1 Immobilizes the patient s head to the device 1 Secures the patient s legs to the device 1 Secures the patient s arms to the device 1 Reassesses motor, sensory and circulatory function in each extremity 1 TOTAL: 14 Did not immediately direct, or take, manual immobilization of the head Released, or ordered release of, manual immobilization before it was maintained mechanically Patient manipulated, or moved excessively, causing potential spinal compromise Patient moves excessively up, down, left or right on the device Head immobilization allows for excessive movement Upon completion of immobilization, head is not in the neutral position Did not assess motor, sensory and circulatory function in each extremity after immobilization to the device Immobilized head to the board before securing the torso

17 Ventilatory Management Dual Lumen Device Insertion Following an Unsuccessful Endotracheal Intubation Attempt Continues body substance isolation precautions 1 Confirms the patient is being properly ventilated with high percentage oxygen 1 Directs the assistant to hyper-oxygenate the patient 1 Checks/prepares the airway device 1 Lubricates the distal tip of the device (may be verbalized) 1 Note: The examiner should remove the OPA and move out of the way when the candidate is prepared to insert the device Positions the patient s head properly 1 Performs a tongue-jaw lift 1 USES COMBITUBE USES THE PTL Inserts device in the mid-line and to the depth so Inserts the device in the mid-line until the bite 1 that the printed ring is at the level of the teeth block flange is at the level of the teeth Inflates the pharyngeal cuff with the proper volume Secures the strap 1 and removed the syringe Inflates the distal cuff with the proper volume Blows into tube #1 to adequately inflate both cuffs 1 and removes the syringe Attaches/directs attachment of BVM to the first (esophageal placement) lumen and ventilates 1 Confirms placement and ventilation through the correct lumen by observing chest rise, 1 auscultation over the epigastrium and bilaterally over each lung Note: The examiner states, You do not see rise and fall of the chest and hear sounds only over the epigastrium. Attaches/directs attachment of BVM to the second (endotracheal placement) lumen and ventilates 1 Confirms placement and ventilation through the correct lumen by observing chest rise, auscultation 1 over the epigastrium and bilaterally over each lung Note: The examiner states, You see rise and fall of the chest, there are no sounds over the epigastrium and breath sounds are equal over each lung. Secures device or confirms that the device remains properly secured 1 TOTAL: 15

18 Ventilatory Management Dual Lumen Device Insertion Following an Unsuccessful Endotracheal Intubation Attempt (continued) Did not take or verbalize body substance isolation precautions Did not initiate ventilations within 30 seconds Interrupted ventilations for more than 30 seconds at any time Did not hyper-oxygenate the patient prior to placement of the dual lumen airway device Did not provide adequate volume per breath (maximum 2 errors/minute permissible) Did not ventilate the patient at a rate of at least 10 breaths per minute Did not insert the dual lumen airway device at a proper depth or at the proper place within 3 attempts Did not inflate both cuffs properly Combitube Did not remove the syringe immediately following the inflation of each cuff PTL Did not secure the strap prior to cuff inflation Did not confirm, by observing chest rise and auscultation over the epigastrium and bilaterally over each lung, that the proper lumen of the device was being used to ventilate the patient Inserted any adjunct in a manner that was dangerous to the patient

19 Ventilatory Management Endotracheal Intubation Note: If a candidate elects to initially ventilate the patient with a BVM attached to a reservoir and oxygen, full credit must be awarded for steps denoted by ** provided the first ventilation is delivered within the initial 30 seconds Takes or verbalizes body substance isolation precautions 1 Opens the airway manually 1 Elevates the patient s tongue and inserts a simple airway adjunct (oropharyngeal/nasopharyngeal airway) 1 Note: The examiner must now inform the candidate no gag reflex is present and the patient accepts the airway adjunct **Ventilates the patient immediately using a BVM device unattached to oxygen 1 **Hyperventilates the patient with room air 1 Note: The examiner must now inform the candidate that ventilation is being properly performed without difficulty Attaches the oxygen reservoir to the BVM 1 Attaches the BVM to high flow oxygen (15 liter per minute) 1 Ventilates the patient at the proper volume and rate ( ml/breath and breaths/minute) 1 Note: After 30 seconds, the examiner must auscultate the patient s chest and inform the candidate that breath sounds are present and equal bilaterally and medical direction has ordered endotracheal intubation. The examiner must now take over ventilation of the patient. Directs assistant to hyper-oxygenate the patient 1 Identifies/selects the proper equipment for endotracheal intubation 1 Checks equipment Checks for cuff leaks 1 Checks laryngoscope operation and bulb tightness 1 Note: The examiner must remove the OPA and move out of the way when the candidate is prepared to intubate the patient. Positions the patient s head properly 1 Inserts the laryngoscope blade into the patient s mouth while displacing the patient s tongue laterally 1 Elevates the patient s mandible with the laryngoscope 1 Introduces the endotracheal tube and advances the tube to the proper depth 1 Inflates the cuff to the proper pressure 1 Disconnects the syringe from the cuff inlet port 1 Directs assistant to ventilate the patient 1 Confirms proper placement of the endotracheal tube by auscultation bilaterally and over the epigastrium 1 Note: The examiner must ask, If you had proper placement, what would you expect to hear? Secures the endotracheal tube (may be verbalized) 1 TOTAL: 21

20 Ventilatory Management Endotracheal Intubation (continued) Did not take or verbalize body substance isolation precautions when necessary Did not initiate ventilation within 30 seconds after applying gloves or interrupts ventilations for greater than 30 seconds at any time Did not voice or provide high oxygen concentrations (15 liter/minute or greater) Did not ventilate the patient at a rate of at least 10 breaths per minute Did not provide adequate volume per breath (maximum of 2 errors per minute permissible) Did not hyper-oxygenate the patient prior to intubation Did not successfully intubate the patient within 3 attempts Used the patient s teeth as a fulcrum Did not assure proper tube placement by auscultation bilaterally over each lung and over the epigastrium The stylette (if used) extended beyond the end of the endotracheal tube Inserted any adjunct in a manner that was dangerous to the patient Did not immediately disconnect the syringe from the inlet port after inflating the cuff

21 Ventilatory Management Esophageal Obturator Airway Insertion Following an Unsuccessful Endotracheal Intubation Attempt Continues body substance isolation precautions 1 Confirms the patient is being ventilated with high percentage oxygen 1 Directs the assistant to hyper-oxygenate the patient 1 Identifies/selects the proper equipment for insertion of EOA 1 Assembles the EOA 1 Tests the cuff for leaks 1 Inflates the mask 1 Lubricates the tube (may be verbalized) 1 Note: The examiner should remove the OPA and move out of the way when the candidate is prepared to insert the device Positions the head properly with the neck in the neutral or slightly flexed position 1 Grasps and elevates the patient s tongue and mandible 1 Inserts the tube in the same direction as the curvature of the pharynx 1 Advances the tube until the mask is sealed against the patient s face 1 Ventilates the patient while maintaining a tight mask-to-face seal 1 Directs confirmation of placement of EOA by observing for chest rise and auscultation over the 1 epigastrium and bilaterally over each lung Note: The examiner must acknowledge adequate chest rise, bilateral breath sounds and absent sounds over the epigastrium Inflates the cuff to the proper pressure 1 Disconnects the syringe from the inlet port 1 Continues ventilation of the patient 1 TOTAL: 17 Did not take or verbalize body substance isolation precautions Did not initiate ventilations within 30 seconds Interrupted ventilations for more than 30 seconds at any time Did not direct hyper-oxygenation of the patient prior to placement of the EOA Did not successfully place the EOA within 3 attempts Did not ventilate at a rate of at least 10 breaths per minute Did not provide adequate volume per breath (maximum 2 errors/minute permissible) Did not assure proper tube placement by auscultation bilaterally and over the epigastrium Did not remove the syringe after inflating the cuff Did not successfully ventilate the patient Did not provide high flow oxygen (15 liters per minute or greater) Inserted any adjunct in a manner that was dangerous to the patient